- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,816.00 / $5,816.00 / $6,907.00
| Facility | | $5,816.00 | $5,816.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,212.09 / $1,341.64 / $1,341.64
| Professional | | $1,212.09 | $1,341.64 | $1,341.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.24 / $1,432.43 / $2,527.64
| Professional | | $1,164.24 | $1,432.43 | $2,527.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,530.00 / $2,530.00 / $2,530.00
| Facility | | $2,530.00 | $2,530.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.30 / $1,412.57 / $3,110.11
| Professional | | $1,150.30 | $1,412.57 | $3,110.11 |